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Imm Waiver Menningoco

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In Compliance with Oklahoma Statutes, Title 70 §3243
Certification of Meningococcal Compliance
Oklahoma Statutes, Title 70 §3243, requires that all students who are first time enrollees in any
public or private postsecondary educational institution in t
his state and who reside in on
-
campus
student housing shall be vaccinated against meningococcal disease. Institutions of higher
education must provide the student or the student’s parents or other legal representative detailed
ociated with meningococcal disease and on the availability and
effectiveness of any vaccine.
The statute permits the student or, if the student is a minor, the student’s parent or other legal
representative, to sign a written waiver stating that the stude
nt has received and reviewed the
information provided on the risks associated with meningococcal disease and on the availability
and effectiveness of any vaccine, and has chosen not to be or not to have the student vaccinated.
Student’s Name:
____________
_________________________________________________________________
Institution:
______________________________________________________________________________
Birth date: _________________________Term/Year of first enrollment: ___________________
Social S
ecurity Number or Student ID: ______________________________________________
1)
I have received and reviewed detailed information on the risks associated with
meningococcal disease, and
2)
I have received and reviewed information on the availability and effecti
veness of any
vaccine (against meningococcal disease), and
3)
I
have been vaccinated or I choose not to be vaccinated* against meningococcal disease.
Signature: ___________________________________________ Date: _____________________
When student is under 1
8 years of age, the following must also be completed:
As the parent, guardian or other legal representative, I certify that the student named above
is a minor and that I have received and reviewed the information provided and that I have
chosen not to ha
ve the student vaccinated against meningococcal disease.
Signature: ___________________________________________ Date: _____________________
*With this waiver, I seek exemption from this requirement. I voluntarily agree to release,
discharge, indemnify a
nd hold harmless Murray State College , its officers, employees and
agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on
account of any loss or personal injury that might result from my decision not to be immunized
against meningitis.
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Imm Waiver Menningoco

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Completed 3 November 2019

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